PSS Request for Special Handling of Payroll Checks Form

Date: * +

Requested by *

AGENCY INFORMATION

Agency/Co#: *

Agency Name: *

Contact Name: *

Email: *

Phone Number: *

EMPLOYEE INFORMATION

Name/Beneficiary (as it appears on check): *

Maildrop Number:

CHECK INFORMATION

Check Date: * +

Date Check Printed: * +

Check Cycle *

On Cycle

Off Cycle

Valid Business Reason for Exemption Request *

Instructions for Special Handling *

Enter the word in the image *
captcha